PROJECT SUMMARY Globally, each year 13 - 20 million people become critically ill and are intubated with mechanical ventilation in an intensive care unit (ICU). In the U.S. alone, there are approximately 1 million intubated, with nearly one-third for >5 days. As many as 73% of these patients will sustain laryngeal injury within 1 day of endotracheal tube placement. For >50 years, research has demonstrated a strong association between endotracheal intubation and laryngeal injury, but without considering the role that patient symptoms may play in identifying such injury. Research in laryngeal injury and voice/communication is a research priority among several professional societies, including the American Association of Critical Care Nurses and the Society of Critical Care Medicine. After extubation, patients often have a range of symptoms related to laryngeal injury and voice changes, including hoarseness, loss of voice, throat clearing, sore throat, and vocal fatigue. At present, patients with such symptoms are not identified as being high-risk for laryngeal injury and are often overlooked with the thought that their symptoms will be self-limited. Such a ?wait and see? approach to laryngeal injury may defer evaluation for 1 week to 3 months (or longer). Unfortunately, this approach has resulted in some patients experiencing serious, long- term consequences, with some injuries resulting in chronic conditions that may have been avoidable with early evaluation and appropriate intervention. Hence, early identification is important, but there is no standard of practice for referral to a speech-language pathologist or laryngologist after extubation for evaluation. The existing literature has important weaknesses, including patient samples that are heterogeneous, poorly described, and often small-sized. In recent years, clinical practice and associated guidelines have changed to target patient wakefulness during intubation with mechanical ventilation, creating a new and important opportunity to interact with patients to evaluate their symptoms during intubation and soon after extubation. Therefore, the overall goals of this research are to systematically: 1) determine patient symptoms related to orotracheal intubation, both during and after intubation, 2) evaluate laryngeal injury and voice function after extubation using advanced methods of laryngoscopy and perceptual and acoustic voice analyses, and 3) construct a screening tool, based on patient and ICU variables and patient symptoms, to assist in identifying patients with clinically important, post- extubation laryngeal injury. This systematic evaluation of patient symptoms, combined with comprehensive laryngoscopic and voice assessment, will inform the development of a clinical screening tool for use by clinicians in the ICU with the aim of appropriately identifying patients needing further evaluation to reduce the short- and long-term harms of endotracheal tube-related injury on the larynx and voice.